There's a protocol specifically designed to prevent wrong-site surgery. It's called the Universal Protocol. It requires verification at multiple points, marking of the surgical site by the surgeon, and a team time-out immediately before incision where everyone confirms they're about to operate on the right patient, on the right site, with the right procedure.
When surgeons operate on the wrong body part, that protocol failed. The question is how—and who let it happen.
The Universal Protocol
After high-profile wrong-site surgery cases made national news, the Joint Commission established mandatory steps that should make these errors virtually impossible. Every hospital performing surgery must implement them. Every surgical team member must participate.
Pre-procedure verification requires confirming correct patient, procedure, and site at multiple points throughout the pre-operative process—during scheduling, at pre-op check-in, before entering the operating room. Site marking requires the surgeon personally to mark the operative site with their initials while the patient is awake and can participate in verification. The time-out happens immediately before incision: the entire surgical team pauses, and together they confirm they have the right patient, the right procedure, the right site, and the right position. No one touches the patient with a scalpel until that verification is complete.
If you had wrong-site surgery, at least one of these steps didn't happen the way it was supposed to. Either verification failed, or marking failed, or the time-out was perfunctory rather than meaningful—or multiple failures compounded into catastrophe.
How It Still Fails
The protocol should work. Its failures are human failures. Busy OR schedules create pressure to move fast, and time-outs become box-checking exercises where someone mumbles the words while everyone else is focused on other things. No one actually stops to verify; they just go through the motions.
Surgical hierarchy inhibits challenge. When the attending surgeon is ready to cut, nurses and techs may feel unable to speak up about concerns. "Stop, did we verify the site?" isn't a question that flows naturally up the hierarchy in many operating room cultures. The people who might catch an error stay silent because the system doesn't empower them to speak.
Site marking gets skipped when it seems obvious. Everyone knows which knee needs surgery—why mark it? Until the patient is draped and prepped and looks like a collection of anatomical regions rather than a person with a clear left and right, and suddenly it isn't obvious at all.
Wrong information propagates. If the consent form has the wrong side listed, every subsequent verification confirms the wrong site. The error entered the system early and no one caught it because everyone was checking documents against documents rather than reality against documents.
The Injuries
Wrong-site surgery causes double harm. First, the unnecessary surgery itself: recovery time from an operation you didn't need, surgical risks that shouldn't have been yours to bear, pain and scarring and possible complications from a procedure that served no medical purpose. Second, your original problem remains. The knee that actually needed surgery still needs surgery. The kidney that should have been removed is still there, still diseased. You face a second operation while recovering from the first, with all the compounded risks that entails.
In the worst cases—wrong-side amputation, removal of the healthy kidney when the cancerous one remains—the harm is irreversible. No amount of money truly compensates for a lost limb that should still be attached to your body, but the law provides compensation because that's the only remedy available for wrongs that can't be undone.
Why These Cases Are Strong
Wrong-site surgery is what lawyers call res ipsa loquitur—"the thing speaks for itself." The very occurrence of the error is proof of negligence. You don't need an expert to explain that removing the wrong kidney falls below the standard of care. No reasonable surgical team intends to operate on the wrong side, so the fact that it happened proves the safety systems failed.
This makes wrong-site surgery cases among the strongest in medical malpractice. The defense can't credibly argue they did nothing wrong. The evidence of error is incontrovertible. The only questions are about damages: how badly were you hurt, and what compensation is appropriate.
Responsibility
The surgeon bears primary responsibility. They're supposed to mark the site. They're supposed to participate meaningfully in verification. They make the incision. The hospital is responsible for implementing the Universal Protocol, training staff to follow it, and enforcing compliance. When the protocol wasn't enforced, when staff weren't trained, when previous near-misses didn't prompt system improvements, the institution failed alongside the individuals.
If you experienced wrong-site surgery, get your records immediately—consent forms, operative notes, time-out documentation. Don't sign anything from the hospital without attorney review; they may try to quietly resolve things in ways that undervalue your claim. Document everything about your physical condition and emotional state. Then consult a malpractice attorney, because these cases are as strong as malpractice cases get, and those responsible should be held accountable.